John Bian

Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis

BACKGROUNDnIndividuals in the USA without private medical insurance are less likely to have access to medical care or participate in cancer screening programmes than those with private medical insurance. Smaller regional studies in the USA suggest that uninsured and Medicaid-insured individuals are more likely to present with advanced-stage cancer than privately insured patients; however, this finding has not been assessed using contemporary, national-level data. Furthermore, patients with cancer from ethnic minorities are more likely to be uninsured or Medicaid-insured than non-Hispanic white people. Separating the effects on stage of cancer at diagnosis associated with these two types of patient characteristics can be difficult.nnnMETHODSnPatients with cancer in the USA, diagnosed between 1998 and 2004, were identified using the US National Cancer Database-a hospital-based registry that contains patient information from about 1430 facilities. Odds ratios and 95% CIs for the effect of insurance status (Medicaid, Medicare (65-99 years), Medicare (18-64 years), private, or uninsured) and ethnicity (white, Hispanic, black, or other) on disease stage at diagnosis for 12 cancer sites (breast [female], colorectal, kidney, lung, melanoma, non-Hodgkin lymphoma, ovary, pancreas, prostate, urinary bladder, uterus, and thyroid) were estimated, while controlling for patient characteristics.nnnFINDINGSn3,742,407 patients were included in the analysis; patient characteristics were similar to those of the corresponding US population not included in the analysis. Uninsured and Medicaid-insured patients were significantly more likely to present with advanced-stage cancer compared with privately insured patients. This finding was most prominent for patients who had cancers that can potentially be detected early by screening or symptom assessment (eg, breast, colorectal, and lung cancer, as well as melanoma). For example, the odds ratios for advanced-stage disease (stage III or IV) at diagnosis for uninsured or Medicaid-insured patients with colorectal cancer were 2.0 (95% CI 1.9-2.1) and 1.6 (95% CI 1.5-1.7), respectively, compared with privately-insured patients. For advanced-stage melanoma, the odds ratios were 2.3 (2.1-2.5) for uninsured patients and 3.3 (3.0-3.6) for Medicaid-insured patients compared with privately insured patients. Black and Hispanic patients were noted to have an increased risk of advanced-stage disease (stage III or IV) at diagnosis, irrespective of insurance status, compared with White patients.nnnINTERPRETATIONnIn this US-based analysis, uninsured and Medicaid-insured patients, and those from ethnic minorities, had substantially increased risks of presenting with advanced-stage cancers at diagnosis. Although many factors other than insurance status also affect the quality of care received, adequate insurance is a crucial factor for receiving appropriate cancer screening and timely access to medical care.

Epidemiology of Recurrent Cerebral Infarction: A Medicare Claims–Based Comparison of First and Recurrent Strokes on 2-Year Survival and Cost

BACKGROUND AND PURPOSEnBecause recurrent strokes will tend to leave patients with greater disability than first strokes, patients with recurrent strokes should have poorer outcomes on average than those with first strokes. The extent of this difference has, however, not yet been estimated with precision.nnnMETHODSnUsing a random 20% sample of Medicare patients aged 65 years and older admitted with a primary diagnosis of cerebral infarction during calendar year 1991, we used historical data from the previous 4 years to classify patients as having either first or recurrent stroke and followed survival and direct medical costs for 24 months after stroke. First and recurrent stroke groups were compared with the log-rank test (survival) and t test (cost) and also multivariate modeling.nnnRESULTSnSurvival from first stroke is consistently better than that for recurrent stroke: 24-month survival was 56.7% versus 48.3%, respectively. Costs were similar for the initial hospital stay and in months 1 to 3 after stroke. During months 4 to 24 after stroke, total costs were higher among those with recurrent stroke by approximately

Insurance status and stage of cancer at diagnosis among women with breast cancer

375/mo across all patients, with this difference being greatest for younger patients and least for patients aged 80 years or older. Most of the difference in total monthly cost was attributable to nursing home utilization (averaging approximately

Regulatory and clinical considerations for biosimilar oncology drugs

150/mo) and acute hospitalization (averaging approximately

Impact of Adjuvant Radiotherapy on Survival after Pancreatic Cancer Resection: An Appraisal of Data from the National Cancer Data Base

120/mo).nnnCONCLUSIONSnPatients with recurrent stroke have, on average, poorer outcomes than those with first stroke. To be as accurate as possible, clinical policy analyses should use different estimates of health and cost outcomes for first and recurrent stroke.

Racial differences in survival post cerebral infarction among the elderly

Individuals without medical insurance or with limited insurance are less likely than those with broader insurance coverage to receive preventive services and to seek timely medical care. The authors examined the associations of insurance status with stage at diagnosis among women with breast cancer.

Outpatient Mastectomy and Breast Reconstructive Surgery

Biological oncology products are integral to cancer treatment, but their high costs pose challenges to patients, families, providers, and insurers. The introduction of biosimilar agents-molecules that are similar in structure, function, activity, immunogenicity, and safety to the original biological drugs-provide opportunities both to improve health-care access and outcomes, and to reduce costs. Several international regulatory pathways have been developed to expedite entry of biosimilars into global marketplaces. The first wave of oncology biosimilar use was in Europe and India in 2007. Oncology biosimilars are now widely marketed in several countries in Europe, and in Australia, Japan, China, Russia, India, and South Korea. Their use is emerging worldwide, with the notable exception of the USA, where several regulatory and cost barriers to biosimilar approval exist. In this Review, we discuss oncology biosimilars and summarise their regulatory frameworks, clinical experiences, and safety concerns.

Unintended Consequences of Health Information Technology: Evidence From Veterans Affairs Colorectal Cancer Oncology Watch Intervention

PurposeThe impact of adjuvant radiotherapy for pancreatic adenocarcinoma (PAC) remains controversial. We examined effects of adjuvant therapy on overall survival (OS) in PAC, using the National Cancer Data Base (NCDB).MethodsPatients with resected PAC from 1998 to 2002 were queried from the NCDB. Factors associated with receipt of adjuvant chemotherapy (ChemoOnly) versus adjuvant chemoradiotherapy (ChemoRad) versus no adjuvant treatment (NoAdjuvant) were assessed. Cox proportional hazard modeling was used to examine effect of adjuvant therapy type on OS. Propensity scores (PS) were developed for each treatment arm and used to produce matched samples for analysis to minimize selection bias.ResultsFrom 1998 to 2002, a total of 11,526 patients underwent resection of PAC. Of these, 1,029 (8.9xa0%) received ChemoOnly, 5,292 (45.9xa0%) received ChemoRad, and 5,205 (45.2xa0%) received NoAdjuvant. On univariate analysis, factors associated with improved OS included: younger age, higher income, higher facility volume, lower tumor stage and grade, negative margins and nodes, and absence of adjuvant therapy. On multivariate analysis with matched PS, factors independently associated with improved OS included: younger age, higher income, higher facility volume, later year of diagnosis, smaller tumor size, lower tumor stage, and negative tumor margins and nodes. ChemoRad had the best OS (hazard ratio 0.70, 95xa0% confidence interval 0.61–0.80) in a PS matched comparison with ChemoOnly (hazard ratio 1.04, 95xa0% confidence interval 0.93–1.18) and NoAdjuvant (index).ConclusionsAdjuvant chemotherapy with radiotherapy is associated with improved OS after PAC resection in a large population from the NCDB. On the basis of these analyses, radiotherapy should be a part of adjuvant therapy for PAC.

Trends in outpatient breast cancer surgery among Medicare fee-for-service patients in the United States from 1993 to 2002.

Objective: To investigate whether there are differences in poststroke survival between African American and white patients, aged 65 and over, in the United States. Methods: A biracial cohort of patients was selected from a random 20% national sample of Medicare patients (age 65 and over) hospitalized with cerebral infarction in 1991, and was followed up to a period of 3 years. The Cox regression model was used for covariate adjustment. Results: A total of 47,045 patients (including 5,324 African Americans) were identified for our analysis. Compared to white patients, African American patients on average were 6% more likely to die post cerebral infarction. The subpopulation analyses further suggest that African Americans age 65 to 74 had much lower 3-year survival probabilities (15 to 20%) than their white counterparts. Conclusions: The authors find evidence of racial disparities in survival post cerebral infarction among the elderly, although the differences by race are not as great as reported elsewhere for stroke incidence and mortality. Future analyses, using more clinically detailed data, should focus especially on whether survival differences by race persist in the young-old (age 65 to 74) population.

Fluoroquinolone-related neuropsychiatric and mitochondrial toxicity: a collaborative investigation by scientists and members of a social network

BackgroundIn the United States, post-mastectomy breast reconstruction is a state (all 51 jurisdictions) and federally mandated benefit. Outpatient mastectomy, which could lower use of breast reconstruction, may raise concerns about whether patients receive adequate post-mastectomy care.MethodsUsing linked surveillance, epidemiology, and end results (SEER)–Medicare data, we identified Medicare fee-for-service women aged 65–69xa0years, diagnosed with early-stage breast cancer, and receiving unilateral mastectomy from 1998–2002. The corresponding surgery delivery settings were determined from claims data. The outcome of interest was reconstruction within 4xa0months of diagnosis. We used multivariable logistic regression models to examine the association of outpatient mastectomy with the likelihood of post-mastectomy reconstruction, controlling for patient’s characteristics.ResultsAmong the 3,419 patients in the sample, 717 (21%) patients received outpatient mastectomy. The proportions of patients receiving reconstruction were 13% for inpatient mastectomy patients and 4% for outpatient mastectomy patients. Outpatient mastectomy patients were younger and had less comorbidities than inpatient mastectomy patients. Multivariable regression analysis suggested that outpatient mastectomy patients were less likely to receive reconstruction (odds ratioxa0=xa00.247; 95% confidence interval (CI): 0.166–0.368). Additional analysis suggests that African American patients were less likely than white patients to undergo reconstruction (odds ratioxa0=xa00.515; 95% CI: 0.293–0.906) and that this ethnic difference was more manifest among patients undergoing inpatient mastectomies.ConclusionsThis study shows that outpatient mastectomy was associated with lower use of breast reconstruction. A better understanding of choice of delivery setting of mastectomy with a focus on younger and minority breast cancer patients should be explored in future research.